BMW Motorrad Unemployment Claim Form

Transcription

1 BMW Motorrad Unemployment Claim Form IMPORTANT INFORMATION WHEN MAKING A CLAIM Incomplete claim forms may cause delay in the assessment of your claim. If you are a company employee please send either an original or certified copy of your redundancy letter. If you are self employed or a company director you need to prove that you or your business has ceased trading and has been formally wound up by a qualified accountant. If you are on a fixed term or short term contract you must provide us with a full copy of the contract. You must provide any other details we request that relates to your claim before we will consider any payments. Proof of income will need to be provided before any claim will be considered. All costs incurred to submit this claim are the responsibility of the claimant. Premiums must continue to be paid on the due date while you are in a claim situation if you require continuous cover. One of our appointed representatives may visit you while you claim. Failure to see them could invalidate or seriously delay your claim. If you qualify for any State Benefit, you should advise the Department for Work and Pensions if you are claiming under this policy. The amount of monthly benefit you receive under this policy may effect your entitlement to State Benefit. The Department for Work and Pensions will be able to provide you with all the details. Please note that this insurance is underwritten by Allianz Insurance PLC who are authorised and regulated by the Financial Services Authority (FSA). This insurance product is administrated by Mondial Assistance Limited who are authorised and regulated by the Financial Services Authority (FSA). Mondial Assistance (UK) Limited will act as agent for Allianz with respect to claims process. Please note that all calls are recorded for accuracy and training purposes. We recommend that you send your claim documents by recorded delivery. Return your completed claim forms as soon as possible in order for us to progress your claim as quickly as we can. Return forms to Claims Department, BMW Motorrad Protect Services, PO Box 1852, Croydon, CR9 1PW. We strongly recommend that you keep copies of your completed claim form and all other supporting documents. Page 1 of 6

2 POLICYHOLDER DETAILS (TO BE COMPLETED BY CLAIMANT) Policy Number Title Last Name First Name(s) Address Post Code Home Telephone Number Mobile Telephone Number Address Would you like to be contacted via in relation to your claim? Date of Birth National Insurance Number Do you have any other income protection or payment protection insurances? If yes, please attach name, address and telephone number of insurer and the monthly benefit amount. EMPLOYMENT DETAILS (TO BE COMPLETED BY CLAIMANT) Please give details of your employment history for the previous 12 months prior to your unemployment. Name, address and telephone number of employer Dates Type of employment From To Permanent, Temporary, Self Employed What was your occupation immediately prior to your unemployment? What was the reason for your unemployment? Employment start date Employment end date What date were you notified of your unemployment? Number of hours worked per week What was your grossed earned income? Did you receive payment in lieu of notice? Payment in lieu of notice From To IF YOUR UNEMPLOYMENT WAS DUE TO REDUNDANCY PLEASE ATTACH A COPY OF YOUR REDUNDANCY LETTER. Page 2 of 6

3 FOR SELF EMPLOYED AND CONTRACT WORKERS ONLY (TO BE COMPLETED BY CLAIMANT) Type of Business How long have you been self employed? Years Months Did you work as a contractor? Did you work as a sub-contractor? Please give the name, address and telephone number of your accountant. IN ORDER TO MAKE A CLAIM WE WILL NEED YOUR Official NOTICE FROM INLAND REVENUE THAT YOU HAVE PERMANENTLY STOPPED YOUR OCCUPATION AND YOUR COMPANY HAS INVOLUNTARILY CEASED TRADING. PLEASE PROVIDE A LETTER FROM THE INLAND REVENUE OR YOUR ACCOUNTANT TO CONFIRM THIS. If you have been working on a contract, please give the following information. Dates contract lasted From To Has your contract prior to your unemployment been renewed, if yes please give dates. PLEASE ATTACH A COPY OF YOUR LAST CONTRACT. Page 3 of 6

4 Employment DETAILS (TO BE COMPLETED BY LAST EMPLOYER/CONTRACTOR) Full name of employee National Insurance Number Employment start date Employment end date What date was the employee first notified of impending unemployment, either verbally or in writing? How many hours was the employee contracted to work per week? Please state if employment was permanent, temporary, for a fixed term, seasonal or other. Was the employee working on a fixed term contract, if so please give details, Dates of contract From To Was the contract renewed? How many times? What was the employee s occupation immediately prior to being made unemployed? Reason for unemployment, e.g. redundancy, resignation. If unemployment was due to redundancy was it voluntary or involuntary? Did the employee receive any payment in lieu of notice? Payment in lieu of notice From To Please give details of employees absence due to illness over the last 12 months. From To Nature of illness Signed Company Stamp Please print name Position Held Date Page 4 of 6

5 DEPARTMENT FOR WORK AND PENSIONS DETAILS (TO BE COMPLETED BY A DWP OFFICER) PLEASE NOTE WE WILL ACCEPT An ORIGINAL COPY OF AN ABI1 FORM Full name of claimant National Insurance Number Date of Claim Date of Birth This certificate to Is the claim continuing? If the claim is no longer continuing, when did the claim end and what was the reason? Has the claimant entered a Government Training Scheme? If yes, when did the claimant start? Is the claim suspended or disallowed? If yes, please give dates and details. Is the claimant active in their search for employment, including going to interviews? If no, please give details as to the reason why. Has the client declared any part time work? If yes, please give dates and details. Signed Official DWP Stamp Please print name Position Held Date Page 5 of 6

6 POLICYHOLDER BANK ACCOUNT DETAILS (TO BE COMPLETED BY CLAIMANT) Please give Bank Account details, for the purpose of benefit payments. Account Number Sort Code Number Please give the name and address of your Bank or Building Society. Postcode Unemployment CLAIM FORM CHECKLIST - Please check you have included all the requested information. Have you completed all parts of your personal and employers details? Yes No If self employed or a contract worker has all relevant documentation been included? Yes No Has your employer completed the form attached? Yes No If you were made redundant have you enclosed a copy of your redundancy letter? Yes No Has your local Department for Work and Pensions completed the form attached? Yes No Have you included a copy of your P60 or last tax assessment? Yes No Application DECLARATION I hereby declare that all information supplied is true in every respect to the best of my knowledge and belief and that I have disclosed all additional information likely to influence the assessment of my claim. I consent to the seeking of information from any person/organisation as deemed necessary by the insurers to verify the answers provided. I understand and agree that information regarding my claim may be shared with other parties for fraud prevention purposes, and that I consent to my claim being investigated as part of this process. DATA PROTECTION ACT I hereby consent to any information about me being processed for the purposes of providing insurance and claims handling, which may necessitate the provision of such information to third parties. Signed Please print name Date Page 6 of 6